Dermatitis artefacta, a psychocutaneous condition resulting from various self-induced injurious behavior, has variable clinical presentations and anonymous prevalence.[1] In this condition, the pathology primarily involves the psyche of the individual concerned.[2] It has well-established association with borderline personality disorder, eating disorders, and dissociative disorders.[3] Self-injurious behavior is as common as 29% in dissociative amnesia as found in a study.[4]

A 38-year-old married female from a rural background presented with complaints of exacerbation of headache, body ache, and anxiety since 3 months. Family members had also complained about her episodes of stupor and spontaneous bleeding from body parts (self-approachable sites such as forearms, chest, and calves) when her headache or anxiety worsened. Although her headache had started since last 6 years, it was manageable with over-the-counter analgesics till 3 months, before consulting us. These episodes were characterized by aggressive and impulsive behavior lasting few minutes, followed by stupor lasting for 20–30 min after which she would forget about the events happened and come out with bleeding from body parts. These episodes of stupor were neither reported during sleep nor associated with seizure-like activity, incontinence, or tongue bite. Three episodes of deliberate self-harm have also been reported in the past 3 months. Premorbidly, she was impulsive and had low frustration tolerance, which was further worsened over the past 3 months. There was no history of convulsive motor movements, incontinence, or tongue bite.

On general physical examination, multiple, superficial, clean-cut incised wounds in different stages of healing were evident [Figure 1] over anterior aspects of both upper and lower extremities and upper chest. During interviews, initially, she denied about self-infliction being cause of these wounds though later she agreed to its possibility by means of shaving blade. She expressed her concern for chronic headache and difficulty in completing household chores with headache.

Figure 1: (a) Computed tomography scan showing ventricular end of the shunt. Note there are no features of hydrocephalus. (b) Shunt along the large bowel loop up to the level of sigmoid colon. (c-e) Shunt tip entry through the appendix tip and the fecal stained pulled out shunt

Neuroimaging, electroencephalogram, and routine hemogram did not reveal any abnormality. The assessment on Rorschach Ink-Blot test revealed impulsivity, emotional instability, and lack of emotional control. The organic causes of headache and stupor were ruled out. She was diagnosed with mixed dissociative disorder (mixture of dissociative stupor and dissociative amnesia) with emotional unstable personality disorder (impulsive type) with tension-type headache.

She was prescribed escitalopram 10 mg/day, amitriptyline 10 mg/day, and naproxen 250 mg whenever required. Her impulsive behavior, poor emotional control, and coping skills were addressed in psychotherapy sessions. With intensive sessions of psychotherapy and pharmacotherapy over 6 weeks, impulsivity, episodes of dissociation, and intensity of headache were reduced, a resultant of which was cessation of bleeding from body parts.

Self-injurious behavior is a closely associated phenomenon with dissociative disorder.[5] Somatic symptoms (headache in this patient) have close association with psychic symptoms (anxiety in this patient) and improvement in one of the domain helps in improvement of the other. Empathetic listening, establishing rapport, and ensuring adequate confidentiality is an essential requisite in the management of such patients.[2],[6]

Improvement of anxiety and pain symptoms in our patient resulted in improvement of the dissociative symptoms as well as self-injurious behavior. Pain produces psychological distress, which might cause dissociation in a vulnerable individual with poor coping skills. Self-infliction of pain during dissociation may counter the pain of headache. Amnesia about self-injurious behavior again may protect the individual from guilt and self-blame.

Acknowledgment

We sincerely acknowledge the help of Dr. Anamika Das for doing language check.